The effect of physiotherapeutic Kinesio taping on selected physical symptoms associated with major depressive disorder

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The effect of physiotherapeutic

Kinesio taping on selected physical

symptoms associated with

major depressive disorder

Karen Erasmus

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The effect of physiotherapeutic Kinesio

taping on selected physical symptoms

associated with major depressive disorder

A research report by

Karen Erasmus

Submitted in partial fulfilment of the requirement for the degree in

MSc (PHYSIOTHERAPY)

In the Physiotherapy Department Faculty of Health Science University of the Free State

24 January 2014

STUDY LEADER: Mrs K. Bodenstein

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Declaration by Study Leader

I, Karen Bodenstein, study leader of Karen Erasmus, hereby confirm that the Department of Physiotherapy, University of the Free State, approves the submission of this script. I certify that the script submitted as partial fulfillment of the requirements for the degree MSc (Physiotherapy) at the University of the Free State is the student‟s independent effort and has not previously been submitted, either partially or as a whole, to the assessors. This script has also not previously been submitted for a degree at another university/faculty.

______________________________ ______________________

Karen Bodenstein Date

Lecturer

Department of Physiotherapy UFS

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Declaration by Student

I, Karen Erasmus, certify that the script hereby submitted by me as partial fulfilment of the requirements for the degree MSc (Physiotherapy) at the University of the Free State is my independent effort and has not previously been submitted for a degree at another university/faculty. I furthermore waive copyright of the script in favour of the University of the Free State.

_____________________________ Karen Erasmus

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Acknowledgments

I want to thank the following people as without them this study and the last 4 years would not have been possible:

 Karen Bodenstein as my study leader in physiotherapy – thank you for your time, advice, patience and support on an academic and personal level. I am very grateful and blessed to have you as my study leader.

 Dr Martie du Toit as co-study leader in psychology..

 Gerda Aspeling, my research assistant and friend. Thank you for the support and companionship during the hours spent at various institutions. To Gerda‟s family, thank you for giving me and this study your time.

 Prof Gina Joubert for the analysis of the data. You were always available with advice and encouragement.

 Karen de Bruin who went above and beyond the call of duty when it came to language editing.

 Tharina Annandale who was willing to check the data forms and was always there with a word of advice and encouragement.

 Jaco Hough for assisting me with the printing.

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List of Figures

Figure 2-1 The longitudinal sine wave on the tape ... 11

Figure 2-2 Kinesio® tape strips ... 13

Figure 2-3 Kinesio® application to skin and effect on underlying structures ... 15

Figure 2-4 Main structures of the limbic system ... 17

Figure 2-5 M. erector spinae ... 25

Figure 3-1 Flowchart of study process ... 34

Figure 3-2 Kinesio® taping according to standardised treatment guidelines ... 39

Figure 3-3 Placebo application – Kinesio® taping not in current guidelines ... 40

List of Tables

Table 2-1 Neurotransmitter system associated with MDD ... 18

Table 4-1 Age distribution across the groups ... 58

Table 4-2 Therapies received during study period ... 59

Table 4-3 Pain complaint areas ... 60

Table 4-4 Pre-application pain scores ... 62

Table 4-5 Post-application pain scores ... 62

Table 4-6 24 hours post-application pain scores ... 63

Table 4-7 Differences between pre-, post-, and 24 hours post-application of the combined components of SF-MPQ ... 63

Table 4-8 Percentage of participants experiencing pain ... 63

Table 4-9 Percentage improvement of SF-MPQ ... 64

Table 4-10 Percentage clinical significant improvement of SF-MPQ ... 64

Table 4-11 The balance of breathing score of the MARM ... 65

Table 4-12 The percentage of ribcage movement score of the MARM ... 66

Table 4-13 Tinetti Mobility Test: Balance and gait scores ... 67

List of Graphs

Graph 4-1 Gender distribution across groups... 57

Graph 4-2 Classification of MDD severity ... 58

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List of Abbreviations

BAS Body Awareness Scale

BAS-H Body Awareness Scale - Health DASH Disability of Arm, Shoulder and Hand

DSM-5 Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition

EMG Electromyography

HAM-D Hamilton Depression Rating Scale

HPCSA Health Professionals Council of South Africa KTA Kinesio® Taping Association

MARM Manual Assessment of Respiratory Motion MDD Major depressive disorder

OSDB Obstructive sleep disorder breathing RSA Respiratory sinus arrhythmia

SF-MPQ Short Form McGill Pain Questionnaire VAS Visual analogue scale

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Abstract

Kinesio® taping is a relatively new form of therapeutic taping that has a variety of applications. Physiotherapists can use the tape to treat certain physical symptoms for example, pain, swelling and dysfunctional muscle activation. Major depressive disorder (MDD) is a mood disorder and physical symptoms most associated with MDD, and tested in this study were muscle tension, pain complaints, restricted breathing, less flexibility and centring of movement. The aim of this study was to investigate the effect of physiotherapeutic Kinesio® taping on selected physical symptoms associated with MDD. A double-blind, randomised controlled design was used, following a quantitative study approach. The study population consisted of 40 patients with MDD admitted to a private and public psychiatric institution in Bloemfontein.

The majority (77.5%) of participants complained of pain during the study period (24 hours) and 58% complained of multiple areas of pain. The sensory and affective components associated with pain and tested by the Short Form McGill Pain Questionnaire (SF-MPQ) showed improvement in combined scores for both the experimental and placebo groups. The results of the Manual Assessment of Respiratory Motion (MARM) displayed improvement in both the placebo and experimental groups for balance of breathing and percentage ribcage motion. The Tinetti Mobility Test which assesses balance and gait showed no distinct results possibly due to the scale not being sensitive enough for the movement disorders tested

Limitations of the study could have influenced the outcomes measured and it should be taken into account that of the 40 participants, 21 received physiotherapy. Other therapies received by participants during the study were not standardised and could not be controlled due to the multitude of stakeholders involved in the care of the patients.

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The treatment of physical symptoms associated with MDD with Kinesio® taping had mixed results, but Kinesio® taping could be a valuable adjuvant treatment modality. The importance of physiotherapy as part of the treatment regime for patients suffering from MDD was highlighted.

Key terms: effects, physiotherapeutic, Kinesio® taping, physical

symptoms, major depressive disorder, pain, restricted breathing, loss of centring of movements

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Chapter 1 Introduction

1.1 Introduction and Background to the Study

Kinesio® taping is a relatively new form of therapeutic taping, using a novel kind of elastic therapeutic tape. The tape and technique was developed by Dr Kenso Kase and differs from classic, non-elastic tape in the sense that Kinesio® tape has a wider treatment approach than just the stabilising and immobilising of joints (Kumbrink, 2012:2). The original concept of Kinesio® taping began in 1973, but the technique is still evolving. The information regarding Kinesio® taping is mostly from books on the subject (Kase, Wallis and Kase, 2003 and Kumbrink, 2012) and is in this stage merely anecdotal as scientific studies on the subject are scarce. Studies on the subject use the methods of Kinesio® taping as set out in the manual written by Kenzo Kase (Kase, Wallis and Kase, 2003:12). This book is currently the reference point on the Kinesio® taping technique. In his book, Clinical Therapeutic Applications of the Kinesio Taping Method, Dr Kase, notes that the development of Kinesio® taping has led not only to theoretical usability but also to a practical approach to the taping method (Kase, Wallis and Kase, 2003:12).

The basic functions and effects of Kinesio® taping can be summarised as follows (Kumbrink, 2012:6; Murray, 2000:1):

Improvement of muscle function Elimination of circulatory impairments Pain reduction

Support of muscle function

Increased proprioception through increased stimulation of the cutaneous mechanoreceptors

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Influencing proprioception and the physiological activity of ligaments and muscles by stimulating cutaneous receptors is older than the Kinesio® taping method; this approach can be traced back to physiotherapy treatments that use manual therapy, rehabilitation and non-elastic taping methods (Kumbrink, 2012:2). Kinesio® taping is used in a variety of treatment settings and for a wide range of conditions (Kumbrink, 2012:6).

Major depressive disorder (MDD) is a mood disorder characterised by a depressed mood. Those suffering from the disorder experience a loss of energy and interest, feelings of guilt, difficulty in concentration, change in appetite and thoughts of death or suicide. Common symptoms of the mood disorder include changes in activity level, cognitive abilities, speech, sleep, sexual activity and biological rhythms. The disorder further almost always causes social and work-related problems (Sadock and Sadock, 2007:527).

Physical symptoms are closely related to MDD and can impede the treatment of the disorder. Physical symptoms associated with the disorder include joint pain, limb pain, back pain, gastrointestinal problems, fatigue, psychomotor activity changes and appetite changes. These symptoms can increase the duration of the MDD episode and cause relapse (Trivedi, 2004:12-13).

Jacobsen, Lassen, Friss, Videbechand Licht (2006:295-296) investigated the physical symptoms most often associated with MDD. These are:

 Muscle tension  Pain complaints  Restricted breathing

 Less flexibility and centring of movements

 Negative attitudes towards physical appearance and ability

Physical symptoms associated with MDD are often ignored in the assessment and treatment of the disorder. Remission of MDD without total relief of the physical symptoms might lead to a false or incomplete remission (Trivedi,

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2004:13). The link between physical complaints and MDD emphasises the need for physiotherapy as part of the holistic treatment regime for the depressed patient. According to the literature (González-Iglesias, Fernández-De-Las-Peñas, Cleland, Huijbregts and Gutiérrez-Vega, 2009:516) certain physical symptoms for example, pain, swelling and dysfunctional muscle activation can be treated by physiotherapists with the use of Kinesio® taping. These physical symptoms are not always associated with MDD despite the fact that a high percentage of patients with MDD in primary care settings only complain of physical symptoms (Trivedi, 2004:12). Considering the abovementioned effects, it is clear that Kinesio® taping could play a role in the mental health field and especially in the treatment of the MDD-associated physical symptoms (Jacobsen

et al., 2006:295-296).

There are several benefits of Kinesio® taping intervention in the field of physiotherapy:

1. It will expand the field of physiotherapy into mental health and psychiatry, and contribute to the clinical guidelines of physiotherapy in psychiatry.

The outcome of the study will contribute to evidence-based research into the treatment of mood disorders through physiotherapeutic intervention.

Kinesio® taping is cost effective as 6 to 10 applications are possible per roll and the taping can be worn for several days without re-application (Kinesio South Africa, 2013).

The treatment allows for supportive therapy at home or in the ward – the taping continues to work as long as it remains on the patient (Kumbrink, 2012:3).

1.2 Research Question

The researcher works in a ward for patients with mood disorders at a public psychiatric institution in Bloemfontein. The ward programme includes physiotherapy assessment and intervention only on referral for physical conditions, secondary to pharmacological and psychotherapy interventions. The

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physiotherapy provided at this institution includes manual therapy, electrotherapy and exercises. The researcher has worked in this specific ward since April 2010 and observed that patients‟ physical complaints decreased with physiotherapy interventions. Kinesio® taping is a new and exciting modality in rehabilitation at the moment. The researcher attended a workshop on the taping in September 2010 and found the concept very interesting. The question therefore arose whether Kinesio® taping as new physiotherapeutic intervention method could have a positive effect on selected physical symptoms associated with MDD.

1.3 Aim and objectives the Study

The main aim of the study was to investigate the effect of physiotherapeutic Kinesio® taping on selected physical symptoms associated with MDD.

The specific objectives of the randomised controlled study, within patients between 18 – 65 years, admitted with major depressive disorder to either a public or private psychiatric institution in Bloemfontein was to:

 determine pain complaints before, immediately after and 24 hours after Kinesio® taping application

 determine areas of pain complaints before, immediately after and 24 hours after Kinesio® taping application

 determine breathing restriction before, immediately after and 24 hours after Kinesio® taping application

 determine flexibility and centring of movements before, immediately after and 24 hours after Kinesio® taping application

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1.4 Literature Review

Research directly linking Kinesio® taping and MDD-associated physical symptoms could not be found during the literature review. However, the literature search did find a number of articles on the physical symptoms of MDD and the treatment of similar symptoms, not associated with MDD using Kinesio® taping. Although the literature review could not link Kinesio® taping directly with the management of the physical symptoms associated with MDD, evidence exists that Kinesio® taping could treat these physical symptoms in isolation and this will be explained in the following paragraphs.

Four of the five physical symptoms associated with MDD (refer to 1.1) as identified by Jacobsen et al. (2006:295-296) were selected to be tested in this study. The fifth symptom, negative attitudes towards physical appearance and ability, falls out of the scope of practice of physiotherapy in mental health. The treatment of these four MDD-associated symptoms with Kinesio® taping is augmented throughout the literature.

Pain can be managed through the use of Kinesio® taping as demonstrated in a case study of a 20 year-old female patient. Application of Kinesio® taping not only improved the range of motion of shoulder abduction and flexion, but on a 10-point visual analogue scale (VAS) pain levels decreased from 10 to 2.7 during movement (García-Muro, Rodriguez-Fernández and Herrero-de-Lucas, 2010:292,294-295).

Kinesio® taping treatment showed that it could improve muscle activity and performance in baseball players during a crossover study with a pre-test/post-test repeated measures design. Measurements were done on strength, electromyography (EMG) or electrical activity in the muscle and scapular motion. The results indicated that taping might have an effect on muscle movement (Hsu, Chen, Lin, Wang and Shih, 2009:2-5,7). Kinesio® taping can further provide stability for task performance. The use of Kinesio® taping improved post-measurement scores of 15 children tested in a

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rehabilitation hospital in Chicago. Upper limb function was assessed by the Melbourne Assessment of Unilateral Upper Limb Function and the scores improved over time, with a mean of 60.5 out of 122 before application of the tape and 70.1 out of 122 at the 3 day follow-up (Yasukawa, Patel and Sisung, 2006:105-109).

The use of Kinesio® taping during a randomised controlled study on shoulder impingement contributed to significantly lower scores on the Disability of Arm, Shoulder and Hand (DASH) scale from a median of 57.5 before treatment to a median of 18 after treatment (Kaya, Zinnuroglu and Tugeu, 2010:203-205).

The use of Kinesio® taping as intervention method is, however, controversial. In a study by Zubeyir, Nilufer, Burcu, Onur, Bahar, Saadet, Gülden (2012) the researchers found no significant effect of Kinesio® taping on primary and accessory respiratory muscle strength. Nevertheless it has to be noted that the researchers did not test volumetric changes as applicable in this study (Zubeyir

et al., 2012:242-244).

This study will examine whether Kinesio® taping can have an effect on selected physical symptoms associated with MDD. Therefore the study will contribute to the current knowledge of Kinesio® taping.

1.5 Significance of the Study

Physiotherapeutic interventions in the treatment of physical symptoms associated with MDD can form an integral part of the treatment regime. The physical symptoms are nonetheless commonly overlooked as being a physical ailment and not part of the psychiatric illness. Insufficient treatment of physical symptoms as part of MDD can lengthen the path of the disease and cause recurrence.

The significance of this study lies in the assessment of a new treatment modality not previously associated with psychiatry. The outcome of the study will also impact on the physiotherapy profession as physiotherapy is not always seen as

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part of the treatment regime for MDD. The study will assist the physiotherapist in treating the patient with MDD in a more effective and holistic manner. It will also emphasise the importance of the physiotherapists as part of the multi-professional team in the treatment of affective disorders.

A greater understanding of the treatment of physical symptoms of MDD will enhance service delivery, improve the quality of care given to patients and minimise the burden of the disease. The results of this study can be used for future presentations or publications and contribute to the body of knowledge in physiotherapy in general and specifically in the treatment of mood disorders.

1.6 Definition of Terms

Kinesio® Tex Gold is a specific elastic therapeutic tape designed for Kinesio®

taping treatment. It is designed and manufactured by Kinesio in Japan and is the material used in this study.

Kinesio® taping is defined as the application of Kinesio® Tex directly to the skin to achieve the therapeutic effects (Donec, Varžaitytė and Kriščiūnas, 2012:98).

Major depressive disorder is diagnosed when one or more major depressive

episodes has occurred. A major depressive episode is characterised by the intensity of sadness that results in “symptoms of reduced pleasure in activities

that used to be pleasurable, weight and sleep disturbance, changes in level of physical activity, fatigue, feelings of worthlessness, reduced ability to concentrate and make decisions, or continuing preoccupation with death or thoughts of suicide. The symptoms must be present most of the day, nearly every day, for a period of at least two weeks” (World Health Organization/German institute of

medical documentation on information, 1994/2006).

Physical symptoms are defined as those physical symptoms most associated

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1.7 Format of the Research Report

The format of the research report for this study is as follows:

Chapter 1 gives an outline of the study. The background, relevant literature and

methodology are briefly explained, and the research question and study objective are stated.

Chapter 2 is an overview of the relevant literature concerned with Kinesio®

taping, MDD and the physical symptoms associated with the disease. Pertinent anatomy is mentioned and the treatment with Kinesio® taping discussed in the light of the physical symptoms associated with MDD.

Chapter 3 is an extensive detailed description of the methodology. Topics

covered are the study design, sample, pilot study, inclusion and exclusion criteria, and ethical considerations.

Chapter 4 presents the results in the form of graphs and tables.

Chapter 5 discusses the results taking into account the available research.

Chapter 6 draws conclusions and makes recommendations. The value of the

study is emphasised and limitations of the study are highlighted.

1.8 Conclusion

This chapter is an overview of the background pertaining to the study as well as the research question that inspired the researcher to formulate the research project. The relevant literature is briefly discussed. In the following chapter a more detailed account of the literature review is given to discuss Kinesio® taping as physiotherapy intervention as well as the specific and selected physical symptoms associated with MDD.

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Chapter 2 Literature Review

2.1 Introduction

In this chapter, an overview of the concepts of the study is given. Kinesio® taping and its applications are examined with regards to its supposed effects and applications. Applicable anatomical structures are discussed and the structures and physical symptoms associated with MDD are investigated in depth.

Information for the literature review was obtained through various search engines on the internet (Google and Google Scholar) and the University of the Free State‟s catalogue (KovsieKat). The following key words were used in the search: “effectiveness”, “Kinesio tape”, “body awareness therapy”, “major depressive disorder”, “breathing”, “pain” and “physical symptoms”. These words were used separately and in different combinations with each other.

2.2 Properties of Kinesio

®

Tape

Kinesiology tape is an umbrella term used for elastic therapeutic tape. Elastic tape differs from the classic taping method in which non-elastic tape is used. Non-elastic tape prevents movement and stabilises joints, whereas elastic tape follows the muscle or nerve path, allowing freedom of movement and influencing lymphatic drainage (Kumbrink, 2012:2,4).

Kinesio® Tex Gold is a brand name of an elastic therapeutic tape by the name of Kinesio® and it was the chosen brand used in this study. It was developed 25 years ago and has become the “platinum” standard for therapeutic rehabilitative tape (Kinesio South Africa, 2013). The literature on Kinesio® taping focused on the decrease of pain and inflammation as well as joint and muscle re-alignment without compromising mobility (García-Muro, Rodriguez-Fernández and Herrero-de-Lucas, 2010:292). The mechanisms proposed were the constant proprioceptive feedback from the skin applications and the facilitation of proximal

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control, space correction, increased lymphatic drainage and pain relief (Kaya, Zinnuroglu and Tugeu, 2010:202).

The original method of Kinesio® taping was developed by Dr Kenzo Kase in 1973 (Kase, Wallis and Kase, 2003:20). It has been used by athletes and clinicians in the sport and medical domains, in the treatment of excessive lymph after mastectomy and surgery (Lipinska, Śliwiński, Kiebzak, Senderek and Kirenko, 2007:256-269; Szczegielniak, Krajczy, Bogacz, Łuniewski and Śliwiński, 2007:299-307; Tsai, Hung, Yang, Huang and Tsauo, 2009:1353-1360) and in the neurological paediatric setting (Yasukawa, Patel and Sisung, 2006:104-108). However, it took centre stage at the 2008 Olympic Games in Beijing when athletes sported the new funky therapeutic tape (Martinez, 2008:1-4).

Kinesio® tape can be used on all body areas and during all the phases of injury and injury prevention (Kinesio® Taping Association [KTA] 2008). The quality and tape properties of different brands of the elastic tape could influence the effect and outcome of the taping (Kumbrink, 2012:3-4).

Acceptable tape qualities are (Kumbrink, 2012:4-5):

1. Cotton fibres woven at right angles to each other. The longitudinal thread must run parallel to the outer edges of the tape.

Elastic fibre woven into the fabric longitudinally must have very specific stretch and endurance limits. Lower elasticity can result in alterations of actions of the tape as well as discomfort during applications.

The acrylic layer allows stretch into a transverse direction by applying it into the tape longitudinally in the form of a sine wave. Refer to Figure 2-1 with regards to the sine wave of a 5 cm strip. The tape itself should only stretch into a longitudinal direction. The forces are distributed horizontally and vertically so that in combination, it allows for the lifting of the skin or underlying tissue. This is one of the principle effects of Kinesio® taping.

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Figure 2-1 The longitudinal sine wave on the tape (Kumbrink, 2012:4)

2.3 The Effects of Kinesio

®

Taping

Kinesio® taping effects focussed on decreasing pain, correcting mal-alignment, increasing vascular and lymphatic flow as well as the correct stimulation of muscle function. The proposed mechanisms exerted by Kinesio® taping were (González-Iglesias et al., 2009:516):

 Increased local blood circulation

 Reduced oedema by decreasing exudative substances  Facilitation of the muscle

 Sensory stimulation and proprioception to the skin, muscle and fascia structures

 Providing proper afferent input to the central nervous system  Limiting range of motion of the affected tissue

The value of Kinesio® taping according to the studies considered lay in the immediate improvement of symptoms (González-Iglesias et al., 2009:516; Kaya, Zinnuroglu and Tugeu, 2010:205). Randomised clinical pre- and post-test studies showed that Kinesio® taping contributed to immediate improvement and resolution of patients‟ symptoms, and that Kinesio®

tape application could be used as a preventative or intervention method (García-Muro, Rodriguez-Fernández and Herrero-de-Lucas, 2010:295; Hsu et al., 2009:7) (refer also

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to 2.8). Standing balance in patients with multiple sclerosis was immediately improved after Kinesio® taping application which implied that the improved results were not due to a learning effect of the patients (Cortesi, Cattanceo and Jonsdottir, 2011:370). Donec, Varžaitytė and Kriščiūnas (2012) however, found that maximal grip force was not influenced directly following Kinesio® taping but that the maximal grip force increased from 11.2 kg at 30 minutes after application to 11.8 kg at 1 hour after application.

There are currently no known side effects of Kinesio® taping. However, the following contra-indications should be considered (Kumbrink, 2012:11):

 Open wounds

 Scars which have not healed

 Skin diseases for example neurodermatitis or psoriasis

 Sacral connective tissue massage zone (genital zone) in the first trimester of pregnancy

 Known allergies to acrylic material

2.4 The Application of Kinesio

®

Tape

Kinesio® tape is applied directly to the skin to achieve the therapeutic effects (Donec, Varžaitytė and Kriščiūnas, 2012:98). Depending on the desired effect required of the Kinesio® taping, the tape is stretched or unstretched. Prior to taping, the tape is cut into “I”, “Y” or fan strips. The base strip is placed without any stretch 2 cm below the area to be treated. Refer to Figure 2-2 for the ways the Kinesio® tape is cut (Rogers, 2009). The corners of the tape should be rounded to prevent premature loosening of the tape. The rounded corners allow the longitudinal forces to be redistributed around the corners (Kumbrink, 2012:9).

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Kinesio tape Y Strip Kinesio X Strip Fan Strip or Fork Strip I strip

Figure 2-2 Kinesio® tape strips (Rogers, 2009)

The method of application of the tape determined the effect on the conditions treated. Corrective application techniques included (Kase, Wallis and Kase, 2003:21):

 Mechanical correction or recoiling  Fascia correction or holding  Space correction or lifting

 Ligament and tendon correction or pressure  Functional correction or spring

 Lymphatic correction or channelling

The space correction method used in this study uses light to moderate or 25-50% available tension. Kinesio® Tex tape was applied to facilitate more space directly over the treatment area. The technique was aimed at the reduction of pain, inflammation and swelling. The application method lifted the skin decreasing pressure in the area. Reduction of pressure in the treatment area decreased the stimulation of chemical receptors, lessened inflammation and therefore decreased pain. The taping methods also led to increased peripheral circulation and activation of the mechanoreceptors and the gate control theory so that pain perception was decreased (Kase, Wallis and Kase, 2003:29).

Control of pain through the gate theory had been described by Melzack and Wall in 1965 and was cited by Low and Reed (1994:78). Pain perception is regulated

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by a gate that can be opened and closed thus increasing or decreasing perceived pain from the peripheral and central nervous system. The pain gate is affected by A-delta (fast) and C-fibres (slow) due to stimulation of the mechanoreceptors in the posterior horn. The morphine effect on the C-fibre system can also be activated by A-delta stimulation and causes stimulation of centres in the midbrain and this can result in serotonin secretion in the posterior horn. The pain gate can be closed via peripheral or inner forces. Inner forces consist of stimulation of large myelinated cutaneous sensory fibres for example, stimulation of the mechanoreceptors (rubbing it better) or via inhibitory control descending from the brain and activated by motivation (Low and Reed 1994:78). Kinesio® taping is applied directly to the skin and the skin serves as the originator of all the proposed effects. The functions of the skin include: sensory perception; immunity; thermoregulation; and homeostasis of water balance (Amirlak, Shahabi, Campbell, Totonchi, Rowe and Soltanian, 2008). The sensory system of the skin monitors information from the internal and external environment as part of homeostatic feedback control of the body (Kibble and Colby, 2009:49). Taping could have an effect on the muscle tone as well as muscle control. Skin receptors and proprioceptors are activated by the application of the tape. Tone regulation is reinforced and information with regards to position in space and muscle effort is relayed (Kumbrink, 2012:7). Refer to Figure 2-3 for the Kinesio® tape application and the underlying structures of the skin (About Kinesio Taping – Concepts & Effects, 2008).

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Figure 2-3 Kinesio® application to skin and effect on underlying structures (About Kinesio Taping – Concepts & Effects, 2008)

2.5 Physiotherapeutic Kinesio

®

Taping

The Health Professionals Council of South Africa (HPCSA) defines the scope of practice for a physiotherapist in the mental health setting as the treatment of physical ailments of psychiatric patients including maintenance or restoration of physical fitness. This includes the use of mechanical aids such as braces, prostheses and other therapeutic and supportive devices, including taping (South African Medical and Dental Council, 1976).

According to Kinesio® Taping South Africa, their Kinesio® taping courses are accredited with the HPCSA and may be attended by chiropractors, physiotherapists, medical doctors, occupational therapists, biokineticists, speech therapists and podiatrists. The course allows the techniques only to be used within the specific scope of practice of the person applying the tape and not outside the specific professional qualification (Kinesio South Africa, 2013).

Physiotherapeutic Kinesio® taping therefore implies the application of Kinesio® Tex utilising the special skill set taught at the course and with the unique approach of a physiotherapist for example, applying the tape to treat the physical symptoms of MDD.

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2.6 Major Depressive Disorder

Mood is a persistent, internal feeling that influences a person‟s behaviour and perception of the world. Mood can be classified as normal (euthymic), increased (euphoric) or depressed (dysphoric). When a patient suffers from a sustained depressed mood, the patient can be diagnosed with a MDD (Sadock and Sadock, 2007:527). The criteria for MDD have been set out in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013:160-161,344-345).

Major depressive disorder is diagnosed when there is a period of at least 2 weeks during which there is either a depressed mood or the loss of interest or pleasure in nearly all activities. Changes in appetite, weight, sleep and decreased energy are reported. Feelings of worthlessness and guilt, and difficulty in thinking, concentration or making decisions are also noted. Suicide ideation plans or attempts or recurrent thoughts of death may also occur (Sadock and Sadock, 2007:527). The DSM-5 has identified psychomotor retardation or agitation as part of the criterion for MDD. Motor disturbances have to be observable by others and not merely subjective feelings of restlessness or being slowed down and it has to be present every day (American Psychiatric Association, 2013:160-161).

Neuro-Anatomy

The limbic system is the collective name for structures in the brain forming the centre for emotion, behaviour, motivation, long-term memory, motor function and olfaction. It consists of a series of cortical and sub-cortical structures that have connections with the reticular formation and hypothalamus (Baily, 2014).

Depression is associated with dysfunction of the limbic system. Refer to

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The limbic system includes the following structures (Kibble and Colby, 2009:106): 1. The cingulated cortex is linked to the highest centres of cognition in the

prefrontal and association areas of the cortex, and is the area where emotion is perceived.

The hippocampus is a curved elevation of grey matter on the medial surface of the temporal lobe and is involved in learning and memory.

The amygdala is situated lateral to the hippocampus and below the basal ganglia. The amygdala is accountable for the perception of strong emotions, for example fear and aggression, and associates emotions with memories.

Figure 2-4 Main structures of the limbic system (Google Images, 2013b)

A relationship appears to exist between the three main monoamine neurotransmitters in the brain (that is, norepinephrine, dopamine and serotonin) and specific symptoms of MDD, for example control of movement. Low levels of these neurotransmitters have been linked with MDD (Maletic, Robinson, Oakes, Iyengar, Ball and Russel, 2007:2035).

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A neurotransmitter is defined as “a chemical contained in the synaptic vesicles in

nerve endings that is released into the synaptic cleft, where it causes the production of inhibitory or excitatory postsynaptic potentials” (Fox, 2008:743).

Refer to Table 2-1 for neurotransmitters associated with MDD (Kibble and Colby, 2009:48).

Table 2-1 Neurotransmitter system associated with MDD

Chemical Synthesis Signal termination General functions in the nervous system

Norepinephrine From dopamine in the catecholamine pathway

Re-uptake or breakdown via the enzymes

monoamine oxidase and catechol-O-mythyltrans-ferase

Alertness General affect

Serotonin From the amino acid tryptophan via the enzyme tryptophan hydroxylase Reuptake Mood (5-HT reuptake blockers are commonly prescribed as anti-depressants) General arousal Dopamine Derived from the

amino acid tyrosine via the enzyme tyrosine hydroxylase in the catecholamine pathway

Reuptake Movement control

and general affect

Patients with MDD often complained of physical symptoms and these symptoms decrease in a linear fashion as the MDD decreases (Jacobsen et al., 2006:295-296).

The most prominent physical symptoms associated with MDD were (Jacobsen

et al., 2006:295-296):

 Muscle tension  Pain complaints

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 Restricted breathing

 Negative attitudes towards physical appearance and ability  Less flexibility and centring of movements

2.7 Current Role of the Physiotherapist in Mental Health

Physiotherapists working in the field of mental health are uniquely placed to provide a broad spectrum of physical approaches to treatment aimed at relieving symptoms, boosting confidence and improving quality of life. Interventions include physical activity, exercise and sport, improvement of balance, postural and movement education, management of chronic or acute pain, manual therapies, acupuncture and complementary therapies (Gray, 2003:xi)

2.8 Selected Physical Symptoms Associated with MDD

Of the five physical symptoms associated with MDD, according to Jacobsen

et al., (2006:295-296), only four can be treated in the scope of practice of the

physiotherapist and with the physical approach of Kinesio® taping. Therefore, the concept of negative attitudes towards physical appearance and ability was omitted from this study. The four selected MDD-associated physical symptoms are augmented throughout the literature, as discussed in the sections below.

2.8.1 Muscle Tension and Associated Pain

Over the last decade several studies have confirmed the relationship between pain and MDD (Bär, Brehm, Boettger, Boettger, Wagner and Sauer, 2005:101-102; Carroll, Cassidy and Cote, 2004:138; Currie and Wang 2004:57-58; Dersh, Gatchel and Polatin, 2001:92-93; Jacobsen et al., 2006:296). Patients diagnosed with MDD have a 50% more likely chance of experiencing chronic neck and low back pain (Carroll, Cassidy and Cote, 2004:137). The reverse is also true: chronic pain is a risk factor for the development of MDD and other psychological disorders (Dersh, Gatchel and Polatin, 2001:92). In a study

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conducted in Canada the incidence of MDD was 19.8% in those patients that experienced chronic low back pain (Currie and Wang, 2004:57). In another study in 1996 by Banks and Kerns cited in Bär et al. (2005:97) the incidence of MDD in patients with chronic low back pain was found to be between 30 and 54%.

Wideman, Scott, Martel and Sullivan (2012:963) found that depressive symptoms in patients referred for physical therapy for the management of musculoskeletal pain conditions would resolve over the course of treatment, and that this resolution was associated with long term recovery. The level of recovery was greater in patients receiving physical therapy than patients not receiving physical therapy (Wideman et al., 2012:963). Furthermore, Jacobsen et al. (2006:296) emphasised that pain was often a result of muscle tension. The combination of pain and muscle tension caused restricted movements and changes in posture. Pain, joint motion and function were successfully treated with Kinesio® taping in a case study of a 20 year-old female patient with acute myofascial shoulder pain. Shoulder mobility was restricted due to pain. A variety of tests to assess the symptoms were preformed including range of motion of abduction, flexion and external rotation as well as the use of a VAS to determine the pain experience. Abduction increased with 125° and flexion with 111° at post-treatment assessment 2 days after the tape was removed. Pain levels decreased from 10 to 2.7 on a 10-point scale during movement. The improvement was hypothesised as being the result of normalisation of muscular function and not merely an analgesic effect. Lower muscle tone, after inhibition of the myofascial trigger points, could account for the decrease in pain. The results of the study might not be widely applicable as the results were only obtained from a single case study. The exact methodology was not mentioned although photos were provided. No mention was made about other therapies received during this time that could have influenced the results (García-Muro, Rodriguez-Fernández and Herrero-de-Lucas, 2010:292,294-295).

Stronger evidence has been obtained for the treatment of muscle pain during a randomised controlled clinical study on 41 patients with whiplash. The

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experimental group obtained a greater improvement in pain and cervical range of motion than the control counterparts. In the experimental group, pain decreased from 4.3 to 3.3 at immediate post-treatment on the numeric pain rating scale (NPRS) where 0 was no pain and 10 was maximum pain. The cervical range of motion (in degrees) for the experimental group from baseline to immediate post-treatment were: flexion 55.8 to 60.7, extension 46.7 to 54.9, right lateral flexion 42.3 to 47.2, left lateral flexion 41.8 to 44.5, right rotation 56.1 to 61.1, left rotation 55.7 to 59.9. Although the results showed a statistically significant reduction in neck pain and increase in cervical range of motion the differences between the groups did not, however, exceed the minimum effect for clinically importance as defined by the authors. Again the results could not be generalized due to the small sample size, follow-up being limited to 24 hours and all patients being treated by the same therapist. A placebo taping cancelled out placebo effects and its influence on the results. It seemed that Kinesio-taping was the only intervention during this time, as the participants were instructed not to drink any medication (González-Iglesias et al., 2009:516-520).

Muscle activity had been improved with Kinesio® tape applications when scapular kinematics and muscle performance were tested in 17 amateur baseball players with shoulder impingement. The study used a crossover, pre-test/post-test repeated measures design. The study compared the effect of elastic and placebo taping. Measurements were performed on strength, EMG and scapular motion in both groups during a movement of scaption (elevation and lowering of the humerus in the scapular plane). Decreased scapular posterior tilt in the Kinesio® taping group suggested that the tape might assist in correcting affected scapular movement and help the arm to function from a more balanced and stable base. The study design was adequate but the sample size was small and did not support statistical strength. The study tested only the immediate effect of the Kinesio® taping but the skin-based application system, used as measuring instrument in the study could have affected the results (Hsu et al., 2009:2-5,7).

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Kinesio® taping has been compared to other physical therapy modalities in a randomised controlled study of 55 patients with shoulder impingement (Kaya, Zinnuroglu and Tugeu, 2010:204-205). The DASH scale and a VAS were used to determine baseline disability and pain scores. The DASH and VAS scores decreased significantly in both groups compared to the baseline evaluation but the DASH scores of the Kinesio® taping group were significantly lower at the second week (a score of 18 compared to 31 in the physical therapy group). The first group received the Kinesio® taping intervention with a full physiotherapy program consisting of a home exercise program and electrotherapy. Group two received all the therapies except Kinesio® taping. Therefore the groups were homogeneous in all aspects except the taping intervention.

Data obtained from 30 voluntary subjects participating in a study on the outcome of Kinesio® taping on lumbar range of motion proved that active range of motion of lumbar flexion increased when the subjects were taped with Kinesio® tape (Yoshid and Kahanov, 2007:104-105,108,111). The effects of Kinesio® taping on the musculoskeletal system had been attributed to a reflex mechanism of the nervous system that causes an increase in recruitment of motor units as well as increased bio-electrical activity and muscle strength. The bio-electrical activity reached its peak 10 minutes after application but the effects lasted for 24 to 48 hours after removal of the tape (Slupik, Dwornik, Bialoszewski and Zych, 2007:650).

2.8.2 Restricted Breathing

Breathing disorders frequently manifest simultaneously with MDD. The prevalence of MDD in chronic pulmonary disorders is up to 80% (Kunik, Roundy, Veazey, Souchek, Richardson, Wray and Stanley, 2005:1208). Respiratory sinus arrhythmia (RSA) have been linked to breathing frequency. High levels of RSA have been associated with poor prognosis of MDD 6 months after the onset of the illness as well as individual symptoms of the MDD. Levels of RSA were

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not linked to MDD severity (Rottenberg, Wilhelm, Gross and Gotlieb, 2002:266,270).

Overlapping similarities between the presenting symptoms and the neurophysiology of MDD and that of obstructive sleep disorder breathing (OSDB) have been demonstrated. OSDB can contribute to or aggravate the symptoms of those predisposed to MDD and the treatment of OSDB can prevent the presentation of depressive symptoms (Deldin, Phillips and Thomas, 2006:137). Jacobsen et al. (2006:296) have explained that restricted breathing and muscle tension are inclined to disrupt the flow of movements, making movement “un-free and disharmonious”. This caused adjustments in posture.

Inspiration is an active process that enlarges the thoracic cavity in three dimensions: transverse, anterior-posterior and vertical (Hamilton and Luttgens, 2002:245 and Moore and Dalley, 1999:72). These dimensions were tested during this study.

An increase of the thoracic cavity in the transverse plane is a result of the elevation and eversion of the lateral portion of the ribs. The shape and anterior-posterior attachments of the ribs are responsible for the so-called “bucket-handle effect”. A lateral movement of the anterior ends of the ribs accompanies the elevation of the lower ribs. This puts the diaphragm on stretch and expands the lower thorax (Hamilton and Luttgens, 2002:245 and Moore and Dalley, 1999:72).

An increase of the thoracic cavity in the anterior-posterior plane is affected by the elevation of the anterior ends of the obliquely placed ribs and the body of the sternum. Rib movement moves the sternum. The elevation of the anterior ends of the ribs causes the ribs to assume a more horizontal position and results in a straightening of the costal cartilages. The movement of the thorax in the transverse and anterior-posterior plane is related to each other. It is a direct result of the shape of the ribs and of the oblique direction of the axes of motion (Hamilton and Luttgens, 2002:245-246 and Moore and Dalley, 1999:70-72).

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An increase in the vertical plane is brought on mainly through the contraction of the diaphragm, but the elevation of the upper two ribs also contributes. During inspiration, the thoracic spine extends to the end range of motion and thereby contributes to the vertical diameter (Hamilton and Luttgens, 2002:246).

Muscles of respiration are divided into muscles of the thorax and muscles of the spine and shoulder girdle. Muscles of the thorax include those associated with rib movement and have a primary function of respiration. Muscles of the spine and shoulder girdle have a secondary function contributing to respiration (Hamilton and Luttgens 2002:246).

Muscles of the thorax and ribs are (Hamilton and Luttgens, 2002:246 and Moore and Dalley, 1999:80-84): the diaphragm; m. intercostales (externi and interni); m. levatores costarum; m. serratus posterior interior; m. serratus posterior superior; and m. transversus thoracis.

Muscles of the spine with a secondary respiratory function include m. abdominals; m. erector spinae; the extensors of the cervical and thoracic spine; m. pectoralis major and minor; m. quadratus lumborum; m. scalenes; m. sternocleidomastoid; and m. trapezius (Hamilton and Luttgens, 2002:246).

M. erector spinae, one of the deep muscles of the back (Snell, 2000: 828-829), stabilises the spine and pelvis against the pull of the abdominal muscles. This results in extension of the spine allowing the abdominal muscles to compress (Hamilton and Luttgens, 2002:250).

Muscles of the back and especially the m.erector spinae are of the utmost importance. The Kinesio® taping is applied directly over the skin area of the muscle and the muscle has a direct function of proximal control as well as volumetric changes of the thorax during breathing. Refer to Figure 2-5 for the m. erector spinae (Google Images 2013a).

Back support greatly influences breathing in the seated position. The abdominal contribution to tidal volume is greater with back support than without back support. This corresponds with lower displacement of the ribcage (in terms of

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perimeter, cross-sectional area and volume changes). This is explained by the effect of tonic contraction of abdominal muscles for postural maintenance and trunk stabilisation. If back support is removed, abdominal compliance is reduced and the motion of the abdominal muscles increases. Abdominal muscles as well as the diaphragm are involved with maintaining posture in the erect position (Romei, Lo Mauro, D‟Angelo, Turconi, Bresolin, Pedotti and Aliverti, 2010:189-190).

Figure 2-5 M. erector spinae (Google Images, 2013a)

Zubeyir et al. (2012) investigated the effect of elastic taping on primary and accessory respiratory muscle strength. The researcher compared the inspiratory muscle strength of 47 subjects. The researchers did not use Kinesio® taping, but a different brand of elastic taped called Pinotape®. The participants were divided into two groups: diaphragmatic kinesiology taping and accessory respiratory muscle kinesiology taping. The researchers found no significant effect on muscle strength of primary or secondary respiratory muscles in healthy subjects. They did, however, not test the volumetric measurements (Zubeyir et al., 2012:242-244).

Kinesio® taping can enhance motor skills, aid stability and improve posture. Kinesio® Tex can also be used to facilitate movement patterns, align posture and

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improve function (Kinesio South Africa, 2013) and therefore Kinesio® taping could have an effect on selected physical symptoms associated with MDD.

2.8.3 Decrease in Flexibility and Centring of Movements

Major depressive disorder has an influence on gait and posture secondary to the motor retardation that predisposes the patients with MDD to falling. Patients that suffer from MDD have a lower motor performance than non-depressed patients and their postural abilities in standing are severely limited compared to their non-depressed equals (Turcu, Toubin, Mourey, D‟Athis, Manckoundia and Pfitzenmeyer, 2004:304,306-307). The more severe the MDD episode, the more impaired the function with regards to motor ability and executive function (Long, 2011).

Decreased flexibility and centring of movements, according to Jacobsen et al. (2006:296), in patients with MDD are represented clinically as a lack of rotation in the trunk, a lack of swinging of the arms during gait, reduced coordination of the arms and a decreased ability to initiate movements from the movement centre (proximal control).

Back extensors posteriorly and abdominal muscles anteriorly are important to facilitate trunk and therefore proximal control. Back extensors that surround the vertebral column provide a flexible support for the trunk (Jaraczewska and Long, 2006:33). The postural tone of the back muscles is important for maintenance of normal curvature of the vertebral column as the muscles extend from the sacrum to the skull (Snell, 2000:828). The muscles provide adjustable tension on the spine allowing the spine to deviate in any direction while maintaining adequate support. A stable thorax is needed for the abdominal muscles to function optimally. Excessive kyphotic posture, muscle weakness or muscle imbalance causes a compression of the ribcage, reducing the volume of the lungs (Jaraczewska and Long, 2006:33).

Kinesio® taping can be used to improve purposeful movement and provide the needed stability and alignment (proximal control) to perform a task (Yasukawa,

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Patel and Sisung, 2006:104). The effect of Kinesio® Tex tape to enhance stability has been demonstrated during a study at a rehabilitation institute in Chicago. Fifteen children with diverse neurological damage, admitted as in-patients, were tested in a pilot study to determine the effects of Kinesio® taping on upper limb function. The children were pre-tested with the Melbourne Assessment of Unilateral Upper Limb Function, taped with Kinesio® taping and re-tested. The results reflected improved post-measurement scores that were statistically significant and that improved over time with a standard deviation of 23.3 at the follow-up measurement after 3 days. This study had a very small sample size of 15 participants and the patients were not uniform with either diagnosis or taping applied, but they presented with the same causes and functional impairments. The assessment tool was standardized and ideal for testing upper limb function. No control was used in this study and the participants received multiple therapies during this time. Although improvement was seen further research is needed to determine the direct impact the taping intervention had on the impairments (Yasukawa, Patel and Sisung, 2006:105-109).

This has also been confirmed by a case study at the same institute. A 12-year-old boy‟s right arm function was evaluated with the Melbourne Assessment of Unilateral Upper Limb Function while he was seated in his wheelchair with the lateral trunk support removed. During testing he displayed dystonic movement and overshooting when trying to grasp objects in front of him. He scored 57 out of the possible 122 (47%) on the scale. The Kinesio® tape was applied bilaterally to the erector spinae muscle from L5 to T2 as well as the shoulder and hand to attain the correct alignment and assist with stability and a functional upright position. Immediately after Kinesio® taping, post-measurement of the upper limb function improved and he scored 61 out of 122 (50%). Three days after wearing the Kinesio® Tex he still scored 50% on the Melbourne Assessment (Yasukawa, Patel and Sisung, 2006:107-108).

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Kinesio® taping has been used in neurological conditions, for example in the treatment of subluxation following a stroke. It has an effect on the sensorimotor system as well as on proprioception (Jaraczewska and Long, 2006:32). The Berg Balance Scale was used to assess the effect of Kinesio® taping on the static balance in subjects with multiple sclerosis. The balance of the subjects improved only in an anterior posterior direction. The reason for this could be that the taping was applied in such a manner that it primarily worked on the flexion-extension movement of the ankle joint. Subjects with poorer quality initial assessments had better outcome from tape application. Kinesio® taping had no adverse effects but results were specific and axis dependent (Cortesi, Cattanceo and Jonsdottir, 2011:366,368-369).

Bicici, Karatas and Baltaci (2012) have tested functional ability including dynamic balance, in basketball players with chronic inversion ankle sprains. Kinesio® Tex did not limit function as in the case of white rigid athletic tape (Bicici, Karatas and Baltaci, 2012:164). Kinesio® tape could be used to promote postural alignment and stability by supporting weak muscles, relaxing overstretched muscles and reducing pain to promote functional activity (Jaraczewska and Long, 2006:37). Kinesio® tape applied directly and without any tension could also stimulate mechanoreceptors and therefore also proprioception (Kase, Wallis and Kase, 2003:36).

The modification of balance and postural control is explained by two theories. Firstly, it is advocated that due to the mechanical properties of Kinesio® taping a reflex reaction is exerted on the nervous system. It causes overlapping of muscle fibres and results in increased muscle activation (sensorimotor effect). Secondly, the application of tape directly to the skin stimulates the feed forward mechanism in the body allowing for an increase in proprioception and joint control (Slupik et al., 2007:650-651).

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2.9 Conclusion

The association between physical complaints and MDD emphasises the need for physiotherapy as part of the holistic treatment regime for the depressed patient. Furthermore Kinesio® taping can facilitate muscles, control joint instability, assist postural alignment as well as relax overused muscles (Kaya, Zinnuroglu and Tugeu, 2010:204-205).

Muscle tension and pain, restricted breathing and decreased centring of movement were successfully treated with Kinesio® taping in the literature as discussed in this chapter. These symptoms correspond with the physical symptoms associated with MDD. Therefore Kinesio® taping could have an influence on selected MDD-associated physical symptoms.

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Chapter 3 Methodology

3.1 Introduction

This chapter discusses all the elements of the methodology of this study. After a thorough literature review, the physical symptoms associated with MDD to be evaluated were selected (refer to 2.8). The aim of the study was refined and specified. The desired study population, which allowed for data gathering, was selected. The study intervention was by means of a Kinesio® Tex taping. Data were collected through standardised questionnaires via closed interviews and observation. A graphic representation of the study process is depicted in 3.3.

3.2 Aim and objectives the study

The main aim of the study was to investigate the effect of physiotherapeutic Kinesio® taping on selected physical symptoms associated with MDD.

The specific objectives of the randomised controlled study, within patients between 18 – 65 years, admitted with major depressive disorder to either a public or private psychiatric institution in Bloemfontein, was to:

 determine pain complaints before, immediately after and 24 hours after Kinesio® taping application as measured by the Short Form McGill Pain Questionnaire .

 determine pain areas before, immediately after and 24 hours after Kinesio® taping application as measured by the Short Form McGill Pain Questionnaire.

 determine breathing restricting before, immediately after and 24 hours after Kinesio® taping application as measured by the Manual Assessment of Respiratory Motion.

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 determine flexibility and centring of movements before, immediately after and 24 hours after Kinesio® taping application as measured by the Tinetti Mobility Test

3.3 Orientation with Regards to the Study Process

3.4 Research Design

Research can take a qualitative or quantitative approach. A quantitative research approach is used to answer a question that can be measured. The research process consists of testing a hypothesis by means of a standardised data collection method. A quantitative research approach collects numerical data and uses statistical analysis to draw conclusions from the data. Quantitative

Writing of research report

Submit coded questionnaires for data analysis to the Department of Biostatistics, University of the Free State

Study experiment completed questionnaires coded

Changes made to protocol, resubmitted to Ethics Committee and consent obtained from second institution

Conduction of study experiment Pilot study

Obtain consent from institution where research is planned

Write and submit the protocol to the Ethics Committee of the Medical Faculty, University of the Free State

Compiling of questionnairs, composing of information and consent form Literature review

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research or an experimental approach confirms or rejects the hypothesis (Leedy and Ormrod, 2005:94-95).

A qualitative research approach strives to explore and interpret certain research aspects. The approach is concerned with themes and categories and the analysis is subjective. The purpose of the study is to describe and understand the phenomena from the participants‟ point of view (Leedy and Ormrod, 2005:94-96).

According to Baily (1997:43-46) an experimental study design has the following properties:

 Manipulation or intervention. The researchers manipulate one or more measurable variables.

 Control. Control is defined as the elimination of interfering influences that are not part of the study design.

 Randomisation. The process reduces systematic bias by ensuring that the study participants are representative of the group (random selection) from the population and ensuring that the placebo control and experimental group participants are similar (random assignment to the groups).

In a randomised controlled study the participants are allocated to either an intervention or control group. The control group receives a placebo treatment which means that the treatment has no known effects but looks similar to the intervention treatment (Morroni and Myer, 2007:89).

A study is blinded when the participants and researchers do not know to which group (experimental or placebo) the study participants are allocated to. In single-blinded studies only the participants are blinded and thus unaware of the group to which they belong. In double-blinded studies, both the participants and researchers are blinded. In triple-blinded studies the participants, researchers and data analysts are blinded (Morroni and Myer, 2007:90).

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With regards to the abovementioned characteristics, this study followed a quantitative research approach: numerical data were collected by means of a standardised procedure (standardised questionnaires) and statistical analysis was used to draw conclusions from the data. This was a double-blind, randomised controlled study: the participants were assigned to either an experimental or control group, and both the researcher administering the evaluation and the participants were unaware of group assignment throughout the study. Keeping the taping area covered with a single layer of clothing ensured further blindness of the said researcher. Refer to Figure 3-1 for the design of the study (Morroni and Myer, 2007:90).

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Figure 3-1 Flowchart of study process Screened for inclusion Excluded Included: study participants that fulfil inclusion critera Consented to participate Randomised Intervention group Pre-application Intervention Post-application 24 hours post-application Control group Pre-application Placebo intervention Post-application 24 hours post- application Refusal to participate

The effect of physiotherapeutic Kinesio taping on selected physical symptoms associated with major depressive disorder

The effect of physiotherapeutic

Kinesio taping on selected physical

symptoms associated with

major depressive disorder

Karen Erasmus

The effect of physiotherapeutic Kinesio

taping on selected physical symptoms

associated with major depressive disorder

Karen Erasmus

MSc (PHYSIOTHERAPY)

Declaration by Study Leader

Declaration by Student

Acknowledgments

Table of Contents

List of Figures

List of Tables

List of Graphs

List of Abbreviations

Abstract

Chapter 1 Introduction

1.1 Introduction and Background to the Study

1.2 Research Question

1.3 Aim and objectives the Study

1.4 Literature Review

1.5 Significance of the Study

1.6 Definition of Terms

1.7 Format of the Research Report

1.8 Conclusion

Chapter 2 Literature Review

2.1 Introduction

2.2 Properties of Kinesio

Tape

2.3 The Effects of Kinesio

Taping

2.4 The Application of Kinesio

Tape

2.5 Physiotherapeutic Kinesio

Taping

2.6 Major Depressive Disorder

2.7 Current Role of the Physiotherapist in Mental Health

2.8 Selected Physical Symptoms Associated with MDD

2.9 Conclusion

Chapter 3 Methodology

3.1 Introduction

3.2 Aim and objectives the study

3.3 Orientation with Regards to the Study Process

3.4 Research Design